Denial of claim definition

Denial of claim means a determination by an insurer or its designee utilization review organization that a medical service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the requirements for medical necessity or other similar basis, and the requested service or payment for the service is therefore denied, reduced or terminated..
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Examples of Denial of claim in a sentence

  • Provide a detailed written sub- stantiation of the claim, in accordance with the requirements of § 725.94(b).(4) Denial of claim.

  • In no event can the extension period exceed a period of 90 days from the end of the initial 90-day period.• Denial of claim: If a claim is wholly or partially denied, the Plan Administrator must notify you within 90 days following receipt of the claim (or 180 days in the case of an extension for special circumstances).

  • Denial of claim: If a claim is wholly or partially denied, the Plan Administrator must notify you within 90 days following receipt of the claim (or 180 days in the case of an extension for special circumstances).

  • M., Cambridge University Press, Cambridge, United Kingdom, 2013.Kohler, P., Hartman, J., and Wolf-Gladrow, D.

  • Office of the Secretary of Family and Social Services; 405 IAC 1-1.4-7) 405 IAC 1-1.4-8 Denial of claim payment proceduresAuthority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2 Affected: IC 4-21.5-3-7; IC 4-21.5-4 Sec.

  • Denial of claim Your right to an External Appeal Your right to appeal a determination that a service is not medically necessaryExperimental, Investigational or Unproven Services shall also be covered when approved by an External Appeal Agent in accordance with an external appeal.

  • Denial of claim Almost four years later, in August 2010, in a suit between IQ and the Villa d’Este Condominium Association, the Association posited that it had never consented to the October 2006 conveyance from Barnard to IQ.3 The Association, however, did not challenge the validity of Barnard’s 2006 sale to IQ.

  • Denial of claim and review procedure: If a claim is wholly or partially denied, the notice of denial must state the specific reason or reasons for the denial, specific references to pertinent Plan provisions on which the denial is based, a description of any additional material or information necessary to perfect the claim, and appropriate information about the steps to be taken if you wish to submit the claim for review.

  • Denial of claim was the most common reason people lodged disputes about this product, followed by delay in claim handling.We also accepted 77 disputes related to trauma insurance products in 2015-16.

  • In no event can the extension period exceed 180 days from the date the claim was initially filed.• Denial of claim: If a claim is wholly or partially denied, the Plan Administrator must notify the claimant within 90 days following its receipt of the claim (or 180 days in the case of an extension for special circumstances).

Related to Denial of claim

  • Denial of Service Attack means an attack intended by the perpetrator to overwhelm the capacity of a "computer system" by sending an excessive volume of electronic data to such "computer system" in order to prevent authorized access to such "computer system".

  • Notice of Claim has the meaning set forth in Section 9.4(a).

  • Notification of Claim means the process of intimating a claim to the insurer or TPA through any of the recognized modes of communication.

  • Denial means the process of refusing to grant a license after OCCL receives an application. This constitutes refusal of permission to operate.

  • AWR Claim means any complaint or claim to a tribunal or court made by or on behalf of the Agency Worker against the Hirer and/or the Employment Business for any breach of the AWR;

  • Proof of Claim and Release means the Proof of Claim and Release form for submitting a Claim, which, subject to approval of the Court, shall be substantially in the form attached hereto as Exhibit A-2, that a Class Member must complete and submit should that Class Member seek to share in a distribution of the Net Settlement Fund.

  • Claims Notice has the meaning set forth in Section 9.3(a).

  • Third party claimant means any individual, corporation, association, partnership, or other legal entity asserting a claim against any individual, corporation, association, partnership, or other legal entity insured under an insurance policy or insurance contract.

  • Fraud Claim means any claim based in whole or in part upon fraud, willful misconduct or intentional misrepresentation.

  • IPR Claim means any claim of infringement or alleged infringement (including the defence of such infringement or alleged infringement) of any IPR, used to provide the Services or as otherwise provided and/or licensed by the Supplier (or to which the Supplier has provided access) to the Authority in the fulfilment of its obligations under this Framework Agreement;

  • Denial notice means a board notification denying an application for the issuance or renewal of a license as required by the Act.

  • Claim Form or “Proof of Claim Form” means the form, substantially in the form attached hereto as Exhibit 2 to Exhibit A, that a Claimant must complete and submit should that Claimant seek to share in a distribution of the Net Settlement Fund.

  • date of claim means the date on which the application or claim is made, or treated as made, for the purposes of this scheme

  • General Release has the meaning stated in Section 6.03.

  • Claim Notice has the meaning set forth in Section 8.4(a).

  • First party claimant means an individual, corporation, association, partnership or other legal entity asserting a right to payment under an insurance policy or insurance contract arising out of the occurrence of the contingency or loss covered by such policy or contract;

  • Third Party Claim has the meaning set forth in Section 8.3.

  • Third Party Claim Notice shall have the meaning set forth in Section 6.5(a).

  • Indemnification Claim has the meaning set forth in Section 12.3.

  • Claimant means a person or entity who or which submits a Claim Form to the Claims Administrator seeking to be eligible to share in the proceeds of the Settlement Fund.

  • Indemnification Claim Notice has the meaning set forth in Section 11.3.

  • Insured Claim means any Claim arising from an incident or occurrence alleged to have occurred prior to the Effective Date that is covered under an insurance policy applicable to the Debtors or their businesses.

  • Release of Claims means the Release of Claims in substantially the same form attached hereto as Exhibit B (as the same may be revised from time to time by the Company upon the advice of counsel).

  • Threat of Release means a substantial likelihood of a Release that requires action to prevent or mitigate damage to the Environment that may result from such Release.

  • Claim for Benefits means a request for a Plan benefit or benefits made by a Member in accordance with the Plan’s Appeals Procedures, including any Pre-Service Claims (requests for Prior Authorization) and Post-Service Claims (requests for benefit payment).

  • Proof of Claim means a proof of Claim Filed against any of the Debtors in the Chapter 11 Cases.